Every finding on record at Bethany Skilled Nursing Facility

Based on observations, record review and interview, the facility failed to ensure Residents at risk for developing pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to prevent new pressure ulcers from developing for one Resident (#54) out of a total sample of 20 Residents. Specifically, for Resident #54, the facility failed to ensure that the air mattress was set to the correct setting as indicated by the physician's order.Findings include:Review of the facility policy titled Alternating Pressure Air Mattress, dated and revised 11/20/21, indicated the following:- Policy: To maintain adequate circulation, relieve pain due to pressure and aid in healing and/or prevention of pressure ulcers.- Procedure: Verify MD order and settings according to manufacturer's guidelines, check settings and function regularly, and check setting on the pump.Review of the facility policy titled Skin Assessment and Decubitus Prevention dated and revised 3/1/24, indicated the following:- In the event that the Norton Scale indicates moderate risk of the Resident has a history of or current pressure ulcers/skin issues, the following Resident Appropriate Interventions may be instituted: determination that the Resident would benefit from a pressure reducing device.Resident #54 was admitted to the facility in May 2023 with diagnoses including type 2 diabetes mellitus, chronic multifocal osteomyelitis and acquired absence of left leg above knee and right toes.Review of Resident #54's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated that the Resident has a Brief Interview for Mental Status score of 11 out of 15 indicating moderate cognitive impairment. Further review of the MDS indicated that the Resident is at risk for developing pressure ulcers/injuries and uses a pressure reducing device for bed.The surveyor made the following observations:-On 6/8/26 at 8:38 A.M., Resident #54 was awake in his/her bed eating breakfast. Resident #54's mattress was an air mattress powered by an air mattress pump, the air mattress pump was set to 320 pounds.- On 6/9/26 at 6:52 A.M., Resident #54 was sleeping in his/her bed with an air mattress in use powered by an air mattress pump. The air mattress pump was set to 210 pounds.Review of Resident #54's physician's order dated 12/29/23 indicated the following:- Weekly skin check by licensed nurse every day shift every Friday for skin monitoring.Review of Resident #54's physician's order dated 6/1/26 indicated the following:- Air Mattress to bed set at approximately 165 lbs. (pounds) (allow for -/+ 10 lbs. variance) - Check setting and function every shift.Review of Resident #45's physician's order dated 4/10/26 indicated the following:- skin prep to right posterior calf BID (twice daily) two times a day for skin monitoring, notify NP (nurse practitioner) for worsening.Review of Resident #54's weight history indicated the most recently recorded weight of 171.2 lbs. on 6/5/26.Review of Resident #54's care plan with a focus on being at risk for impairment to skin integrity related to diabetes disease process, vascular disease, obesity, decreased mobility, incontinence with a revised date of 6/16/25 indicated the following interventions: air mattress, complete Norton Assessment per facility protocol, implement preventative measures where necessary.Review of Resident #54's Norton Plus Pressure Ulcer Assessment (an assessment that indicates the risk of developing pressure ulcers) dated 5/6/26 indicated that the Resident is at a high risk of developing pressure ulcers as indicated by a score of eight.Review of Resident #54's progress note dated 3/10/26 at 3:42 P.M. indicated the following: Resident observed crying and complained of increased pain in right lower leg today and over weekend. Skin is intact. No redness or warmth observed. NP notified.Review of Resident #54's progress note dated 4/10/26 at 1:40 P.M., indicated the following: Resident complaining of discomfort to his/her right calf. Skin is warm, dry and intact with blanchable redness and tenderness with palpitation. NP notified with new orders to apply skin prep to the site BID and notify MD/NP for any worsening.Review of Resident #54's weekly skin check assessments indicated the following:- 4/10/26: weekly skin check by licensed nurse every day shift every Fri for skin monitoring Fridays 7-3 (7:00 A.M - 3:00 P.M.) Resident compliant with bed bath. Skin is warm, dry and intact. Right posterior calf has blanchable redness and tenderness w/ palpitation. Skin prep applied.- 4/17/26: weekly skin check by licensed nurse every day shift every Fri for skin monitoring Fridays 7-3. Resident had bed bath. skin is warm, dry and intact. Right calf continues with blanchable redness. Skin prep being applied bid.4/24/26: weekly skin check by licensed nurse every day shift every Fri for skin monitoring Fridays 7-3 Resident had bed bath. Skin is warm, dry and intact. Right calf continues with blanchable redness. Nursing continues to apply skin prep BID. No new skin issues observed.5/1/26: weekly skin check by licensed nurse every day shift every Fri for skin monitoring Fridays 7-3 Resident had bed bath. Right calf continues with blanchable redness. Skin prep applied to site BID. No new skin issues observed.5/15/26: weekly skin check by licensed nurse every day shift every Fri for skin monitoring Fridays 7-3 right calf continues with blanchable redness. Nursing to continue to apply skin prep bid. No new skin issues observed.5/22/26: weekly skin check by licensed nurse every day shift every Fri for skin monitoring Fridays 7-3 right calf continues with blanchable redness. Skin prep being applied 2x/day. No new skin issues observed.5/29/26: weekly skin check by licensed nurse every day shift every Fri for skin monitoring Fridays 7-3 skin is warm, dry and intact. right calf continues with blanchable erythema. Nursing continues to apply skin prep bid. No new skin issues noted.6/5/26: weekly skin check by licensed nurse every day shift every Fri for skin monitoring Fridays 7-3 skin is warm, dry and intact. left calf [sic] continues with blanchable erythema. Nursing to continue to apply skin prep bid. No new skin issues observed.During an interview on 6/9/26 at 7:17 A.M., Nurse #1 said the facility is doing skin prep on Resident #54's calf as the skin has been red and blanchable and we try and offload it. Nurse #1 then said Resident #54 has a history of having his/her left leg amputated as well as his/her right toes being amputated due to his/her diabetes and he/she is at risk of developing pressure ulcers. Nurse #1 said Resident #54 has an air mattress as pressure ulcer prevention which is set to his/her body weight as indicated in the physician's order. Nurse #1 said if the air mattress is set too high it will not properly offload the pressure, Nurse #1 and the surveyor proceeded to observe the air mattress pump set to 210 pounds and Nurse #1 said it was too high and adjusted it lower to 170 pounds.During an interview on 6/9/26 at 7:31 A.M., Unit Manager #1 said Resident #54 has type 2 diabetes and has a history of his/her left leg being amputated because of his/her diabetes. Unit Manager #1 said the Resident is at risk for skin issues and pressure ulcer development and has a history of pressure ulcers. Unit Manager #1 said Resident #54 used to have a pressure ulcer on his/her right calf but now it is healed but the skin has been reddened and blanchable. Unit Manager #1 then said the Resident is on an air mattress for pressure ulcer prevention and it should be set to within 10 pounds of his/her body weight. Unit Manager #1 said the air mattress gets monitored daily so she was not sure why it was set to 320 and 210 pounds; she continued to say that the air mattress being that high would put too much pressure on Resident #54's skin.Review of Resident #54's paper medical record chart indicated an Interdisciplinary Rehabilitation Screening form completed by Unit Manager #1 indicating the following: Skin Integrity: Nursing concerns about skin integrity/pain to right calf region where prior wound was. OT (occupation therapy) eval (evaluation) indicated. The Form was signed by the Director of Rehab on 6/9/26.During an interview on 6/9/26 at 7:56 A.M., the Director of Rehab (DOR) said therapy is evaluating Resident #54 because Unit Manager #1 told her they are concerned the Resident's calf area might be worsening so Unit Manager #1 put in a referral for offloading adaptive equipment. The DOR then said Resident #54 has a horrible history of wounds and he/she almost had his/her right leg also amputated as well.During a telephone interview on 6/9/26 at 9:40 A.M., Nurse Practitioner (NP) #1 said Resident #54 had a chronic open wound on his/her right calf in the past because of his/her diabetic status and he/she is at risk for his/her skin to worsen in that area again. NP #1 then said Resident #54 uses an air mattress to reduce the pressure on his/her calf area and the air mattress should be set to his/her weight. NP #1 then said having his/her air mattress set to 320 and 210 pounds is too high and it will not relieve the pressure correctly.During an interview on 6/9/26 at 10:20 A.M., Resident #54 said he/she never touches the air mattress pump dial.During a follow-up interview on 6/9/26 at 10:28 A.M., the DOR said Occupational Therapy evaluated Resident #54's need for offloading adaptive equipment. The DOR said it was reported to her that Resident #54's right calf area was reddened. The DOR and surveyor reviewed the Occupational Therapy Evaluation, and it indicated the following: Reason for Referral: Resident #54 was referred to OT due to right LE (lower extremity) calf skin integrity concerns and need for OT evaluation for adaptive equipment to prevent skin breakdown.During a follow-up interview on 6/9/26 at 10:28 A.M., Unit Manager #1 said she spoke with some Certified Nursing Assistants (CNAs) who said they may have bumped into the air mattress pump and moved the dial.During an interview on 6/9/26 at 11:19 A.M., the Assistant Director of Nursing (ADON) said Resident #54's air mattress should be set to his/her weight as mentioned in the physician's order. The ADON then said the air mattress is not serving its purpose of reducing pressure if it is set to 320 and 210 pounds. The ADON then said CNAs should not be adjusting the air mattress pump and nursing should be checking it daily to ensure it is at the correct setting.

Based on observation, record review and interview the facility failed for two Residents (#69 and #25), out of a total sample of 20 residents, to ensure the Minimum Data Set (MDS) assessments accurately reflected the Residents status. Specifically:For Resident #69 the facility staff failed to ensure the MDS assessment accurately reflected the presence of a Moisture Associated Skin Damage (MASD) wound, andFor Resident #25 the facility staff failed to ensure the MDS assessment accurately reflected the Resident was receiving hospice care services. Findings include:1. Resident #69 was admitted to the facility in May 2016 and has diagnoses that include chronic kidney disease, and functional urinary incontinence.Review of the most recent Minimum Data Set (MDS) assessment, dated 5/7/26, indicated Resident #69 scored 15 out of 15 on the Brief Interview for Mental Status Exam (BIMS) indicating he/she as cognitively intact. Further, the MDS indicated Resident #69 requires supervision/touching assistance for toileting, requires substantial/maximal assistance for bathing and dressing, and is at risk for developing pressure ulcer/injuries. The MDS did not indicate Resident #69 had any unhealed pressure ulcers/injuries or other ulcers, wounds and skin problems, including Moisture Associated Skin Damage (MASD).During an observation and interview on 6/8/26 at 8:39 A.M., Resident #69's bed had an air mattress pump affixed to the foot board. When asked if the air mattress was for prevention or if he/she had a wound Resident #69 said he/she had a wound on his/her lower back and that it was getting better. Resident #69 said the staff provide a dressing or treatment most days. Review of the Treatment Administration Record dated May 2026 indicated the following order: Coccyx: Cleanse with normal saline and pat dry. Apply moistened collagen to wound bed and cover with 2 x 2 bordered foam dressing every day shift for wound care, start date 5/1/26 and DC (discontinue date) 5/7/26. Review of a progress note titled 'skin/wound' note dated 5/1/26 indicated Resident was seen during wound rounds for ongoing eval (evaluation) and treatment recommendations for an open area (MASD) to the coccyx area. Area measuring 0.2 CM x 0.2 cm. Periwound pink and blanchable. Scant serous drainage. No odor, no s/sx (sign/symptoms) of infection. Recommendation reviewed with NP (nurse practitioner). NP in agreement to d/c (discontinue) current treatment and begin the following: Coccyx: Cleanse with normal saline and pat dry. Apply moistened collagen to wound bed and cover with 2 x 2 bordered foam dressing. During an interview on 6/9/26 at 9:08 A.M., Minimum Data Set (MDS) Nurse #2 said when she completes an MDS assessment she gathers information from the wound team, risk meetings and from the IDT (interdisciplinary team) and reviews the medical record. MDS Nurse #2 said she thought the MASD wound on Resident #69's coccyx healed and she did not code it on the MDS. MDS Nurse #2 reviewed the TAR, and the progress note and said the MASD wound should have been coded on the 5/6/26 MDS. During an interview on 6/9/26 at 10:36 A.M. the Assistant Director of Nursing ADON) said Resident #69 had a MASD area on his/her coccyx and it resolved (healed) on the date that was documented in the record, which was 5/7/26. The ADON said it resolved 5/7/26 and should have been captured on the MDS.2. Resident #25 was admitted to the facility in May 2026 and has diagnoses that include atherosclerotic heart disease, and chronic respiratory failure. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #25 scored 12 out of 15 on the Brief Interview for Mental Status exam, which signifies he/she has moderately impaired cognition. During an interview on 6/8/26 at 9:41 A.M., Resident #25 said they say I am on hospice, so I am going to die sometime.Review of Resident #25's clinical record indicated the following: -A physician's order dated 5/20/26, Admit to (provider name) Hospice effective 5/20/26. -A hospice binder with a CTI (certificate of terminal illness), with a certification period of 5/20/26 through 8/17/26.Review of the MDS dated [DATE] failed to indicate Resident #25 was receiving hospice care services. During an interview on 6/9/2026 at 8:28 A.M., the Hospice Certified Nursing Assistant said she has been coming to the facility to care for Resident #25 for the last few weeks. During an interview on 6/9/26 at 8:30 A.M. Nurse #2 said Resident #25 has been on hospice care since his/her admission to the facility.During an interview on 6/9/26 at 8:52 A.M., MDS Nurse #1 said Resident #25 should have been coded as receiving hospice care on the comprehensive MDS dated [DATE] and it was missed.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the use of a Hoyer lift (mechanical mobility aid that supports a person's body weight to allow movement from one surface to another) with assistance of two staff members for all transfers, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety and prevent an incident/accident resulting in multiple injuries, when on 08/22/24, Certified Nurse Aide (CNA) #1 initiated a Hoyer lift transfer with Resident #1 from his/her wheelchair, without another staff member present to assist her, and Resident #1 slid forward in the Hoyer lift pad and fell forward onto the floor. Resident #1 was transferred to Hospital Emergency Department where he/she diagnosed with a scalp laceration, head injuries, fractures and was admitted . Findings include: Review of the Facility's Policy, titled Mechanical Lifts, dated as reviewed January 2024, indicated the following: - Two staff members must be present during the transfer, and - One staff (member) will monitor the clip/loop placement and steady the resident, while the second staff member will use the control to lower the resident into position. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 08/27/24, indicated that on 8/22/24, a staff member (later identified as CNA #1) was preparing the resident for a transfer to bed from his/her wheelchair via mechanical lift (Hoyer). The Report indicated that Resident #1 became agitated and yelled, my butt is hurting, so CNA #1 raised Resident #1 slightly up off the wheelchair to relieve pressure on his/her buttocks. The Report indicated that Resident was kicking and flailing, and then slid out of the Hoyer pad landing on the floor. The Report indicated that Resident #1 was transferred to the Hospital Emergency Department (ED) and diagnosed with a right clavicle (collar bone) fracture, question of a right temporal bone (side of skull) fracture, a scalp laceration requiring five staples and a subarachnoid/subdural hemorrhage (brain bleeds). The Report indicated that Resident #1 returned to the Facility within 24 hours. Review of the Facility's Fall Investigation, dated 08/22/24, indicated that Resident #1 was being prepared to transfer from his/her wheelchair to bed via mechanical lift. The Investigation indicated Resident #1 became agitated, flailing, kicking, and yelling, and then he/she slid to the floor hitting his/her head. The Investigation indicated that the root [cause] of the fall was that Resident #1 became agitated and combative while he/she was prepared for care and slid down the chair. However, the Investigation findings did not include that CNA #1 was alone at the time of Resident #1's fall and did not have another staff member with her when she lifted him/her up off the wheelchair, with the Hoyer lift. Review of Resident #1's Hospital Discharge Report, dated 08/23/24, indicated that Resident #1 was evaluated in the Hospital's Emergency Department after a fall from a Hoyer lift, and then admitted to the Hospital's Surgical Intensive Care Unit (SICU). The Report indicated that a computerized tomography (CT) scan of Resident #1's head on 08/23/24 at 4:00 A.M., revealed worsening subdural and subarachnoid hemorrhages (brain bleeds) compared to a prior CT scan done on 08/22/24. The Report indicated that Resident #1's injuries were deemed non-operative given his/her Do Not Resuscitate/Do Not Intubate status. The Report indicated that Resident #1 also had an occipital (back of head) wound that required staples for closure, a right temporal bone (side of skull) fracture, and a right clavicle (collar bone) fracture. The Report indicated that Resident #1 was sent back to the facility on [DATE]. Resident #1 was admitted to the Facility in March 2017, diagnoses included dementia, and major depressive disorder. Review of Resident #1's Activities of Daily Living Care Plan, reviewed and renewed with his/her June 2024 Quarterly MDS, indicated that Resident #1 required a Hoyer lift with the assistance of two staff members for transfers. Review of Resident #1's Behavior Care Plan, reviewed and renewed with his/her June 2024 Quarterly MDS, indicated that if Resident #1 resists ADLs, reassure him/her, leave and return five to ten minutes later to try again. During an interview on 09/26/23 at 3:03 P.M., (which included a review of her Written Witness Statement dated, 08/23/24), CNA #1 said she was in Resident #1's room waiting for CNA #2 to come and assist her with Resident #1's transfer. CNA #1 said Resident #1 was seated in his/her wheelchair on a Hoyer pad when he/she started yelling, my butt hurts. CNA #1 said she attached the Hoyer pad straps to the Hoyer lift, pressed the lift button on the Hoyer lift, and lifted him/her (Resident #1) up a little. CNA #1 said when she lifted Resident #1 up with the Hoyer lift, his/her combative behavior worsened and Resident #1 fell forward out of the Hoyer pad onto the floor. CNA #1 said she was standing in front of Resident #1 when she lifted him/her up in the Hoyer lift, but she was unable to stop him/her from falling to the floor and hitting his/her head. CNA #1 said she was aware that tow staff members needed to be present when doing Hoyer lift transfer, but that she did not wait for CNA #2 to come to assist her [with the transfer] because Resident #1 was yelling. During the interview with the surveyor, CNA #1 physically demonstrated how she lifted Resident #1 up alone in the Hoyer lift, and how he/she fell forward out of the Hoyer lift onto the floor. When CNA #1 reenacted the incident, she had the surveyor play her role as the only CNA present in Resident #1's room, and she (CNA #1) played the role of Resident #1. CNA #1 had the surveyor stand in front of her while she was seated in a chair. CNA #1 then demonstrated how Resident #1 fell from the raised Hoyer lift pad, by leaning her upper body far forward in her seat and then moving her entire body head-first toward the floor. During a telephone interview on 10/02/24 at 10:31 A.M., (which included a review of a statement obtained during a telephone interview conducted by the Director of Nurses, dated 08/23/24), CNA #2 said on 08/22/24, she was providing care to another resident in another room, when she heard CNA #1 yell her name. CNA #2 said when she arrived at Resident #1's room, she saw Resident #1 lying on the floor and blood was coming from his/her head. During an interview on 09/26/24 at 11:21 P.M., (which included a review of her Written Witness Statement dated 08/22/24), Nurse #1 said she was familiar with Resident #1 and said he/she required a Hoyer lift with two staff members present to assist for transfers. Nurse #1 said CNA #1 and CNA #2 called her to Resident #1's room, and when she entered his/her room, she saw Resident #1 lying on the floor on his/her back between the bed and the Hoyer lift, and he/she had blood coming from his/her head. During a telephone interview on 10/03/24 at 1:40 P.M., Nurse #2 said she heard CNA #1 and Nurse #1 yell to her to call 911. Nurse #2 said that after she called 911 and notified Nursing Supervisor #1, she entered Resident #1's room and saw Resident #1 lying on the floor on his/her back with blood near his/her head. Review of a Progress Note, written by Nursing Supervisor #1, dated 08/22/24 at 7:35 P.M., indicated that Resident #1 was being transferred via Hoyer Lift, became anxious and agitated, flailing and kicking, and then slid out of the Hoyer pad onto the floor in the supine (lying on back) position, hitting his/her head on the floor. The Note indicated Resident #1 was visibly bleeding from his/her head and that he/she had a laceration on the back of his/her head. The Note indicated that Resident #1's mobility order was Hoyer lift with an assist of two staff members. During an interview on 09/2624 at 1:18 P.M., Nursing Supervisor #1 said Nurse #2 called her to come emergently to Resident #1's room, and when she arrived, she saw Resident #1 lying on the floor with blood coming from the back of his/her head. Nursing Supervisor #1 said CNA #1 told her that Resident #1 had been yelling, kicking, and flailing in his/her wheelchair, and screaming that his/her butt hurt, so she tried to relieve pressure on Resident #1's buttocks while she waited for CNA #2 to assist her, by lifting him/her up off the wheelchair [with the Hoyer lift]. Review of an Employee Warning Form, dated 08/23/24, completed by the Staff Development Coordinator (SDC) indicated that CNA #1 was issued a written warning because of the incident with Resident #1. During a telephone interview on 10/03/24 at 12:08 P.M., the Staff Development Coordinator (SDC) said she completed the Employee Warning Form on 08/23/24 for CNA #1 because she (CNA #1) lifted Resident #1 up in the Hoyer lift without having another staff member present to assist her, which caused Resident #1 to fall. The SDC said that per Facility Policy, two staff members are required to be present for all Hoyer lift transfers. The SDC said that a transfer begins as soon as staff members use a Hoyer lift to start lifting the resident from the surface, he/she is seated on. During an interview on 09/26/24 at 1:37 P.M., the Director of Nurses (DON) said that when she interviewed CNA #1, CNA #1 told her that the Hoyer pad was connected to the Hoyer lift and that she slightly lifted Resident #1 up with the Hoyer lift without the assistance from another staff member. The DON said when CNA #1 went into Resident #1's room, Resident #1 became agitated and combative as soon as CNA #1 started hooking up the Hoyer pad to the machine. The DON said that following this incident, the Facility had determined that going forward, for any resident requiring a Hoyer lift for transfers, two staff members must enter the resident's room simultaneously. On 09/26/24, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction provided is as follows: A. 8/22/24, Nursing immediately assessed Resident #1 for injuries, 911 was initiated and he/she was transferred to the Hospital Emergency Department, he/she returned within 24 hours. B. 8/23/24, The Staff Development Coordinator (SDC) initiated staff education on the use of mechanical lifts and all nursing staff were required to complete an additional Mechanical Lift competency that included return demonstration. C. Effective 08/23/24, daily visual observation audits by Nursing administration on the day and evening shifts were initiated to ensure two staff members were present for Hoyer lift transfers. Observation Audits will continue for 60-90 days D. 8/24/24, Resident #1 returned to the facility and his/her Comprehensive Care Plan was reviewed and revised. E. 8/26/24, The Facility recognized that all residents have the potential to be affected by the same deficient practice, and the DON completed a facility-wide audit for all Residents requiring Hoyer lifts which included a review of their Comprehensive Care Plans. F. 09/03/24, the Director of Rehabilitation (DOR) completed facility-wide audit of all residents requiring a Hoyer lift, to ensure the correct Hoyer pads were being used on all residents according to manufacturer's guidelines. G. 09/10/24, the area of concern and data collected, was presented at the Facility's Quality Assurance Performance Improvement (QAPI) Committee Meeting, and a QI project was developed. H. The Administrator, the Director of Nursing and/or their designees will be responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose comprehensive plan of care indicated he/she required the use of a Hoyer lift (mechanical mobility aid that supports a person's body weight to allow movement from one surface to another) with assistance of two staff members for all transfers, and that staff should reapproach him/her if he/she became combative with care, the Facility failed to ensure staff implemented and followed interventions in his/her care plan, when on 8/22/24, while waiting to be transferred back to bed, Resident #1 became agitated, and per Certified Nurse Aide (CNA) #1, she lifted Resident #1 up from his/her wheelchair with a Hoyer lift to relieve pressure from Resident #1's buttocks, however CNA #1 did so, without having another staff member present to assist her, and Resident #1 slid out of the Hoyer lift pad and fell forward onto the floor. Resident #1 was transferred to the Hospital Emergency Department (ED) where he/she was diagnosed with a scalp laceration, head injuries, fractures and was admitted . Findings include: Review of the Facility's Policy titled, Resident Care Planning, dated March 2017, indicated that: - the Facility provides individualized, person centered care which is reflected in each resident's care plan. To facilitate the creation of such plans, the Facility performs a comprehensive assessment on all residents, -the care plan will include an assessment of resident's strengths and needs and, -the care plan may be accessed by any person involved in the implementation of the care plan. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 08/27/24, indicated that on 8/22/24, a staff member (later identified as CNA #1) was preparing the resident for a transfer to bed from his/her wheelchair via mechanical lift (Hoyer). The Report indicated that Resident #1 became agitated and yelled, my butt is hurting, so CNA #1 raised Resident #1 slightly [up off the wheelchair using the Hoyer lift] to relieve pressure on his/her buttocks. The Report indicated that Resident was kicking and flailing, and then slid out of the Hoyer pad landing on the floor. The Report indicated that Resident #1 was transferred to the Hospital Emergency Department (ED) and diagnosed with a right clavicle (collar bone) fracture, question of a right temporal bone (side of skull) fracture, a scalp laceration requiring five staples and subarachnoid/subdural hemorrhages (brain bleeds). The Report indicated that Resident #1 returned to the Facility within 24 hours. Review of the Facility's Fall Investigation, dated 08/22/24, indicated that Resident #1 was being prepared to transfer from his/her wheelchair to bed via mechanical (Hoyer) lift. The Investigation indicated Resident #1 became agitated, was flailing, kicking, and yelling, and then slid to the floor hitting his/her head. The Investigation indicated that the root [cause] of the fall was that Resident #1 became agitated and combative while he/she was prepared for care and slid down the chair (lift pad). Review of Resident #1's Hospital Discharge Report, dated 08/23/24, indicated that Resident #1 was evaluated after a fall from a Hoyer lift, and he/she admitted to the Hospital's Surgical Intensive Care Unit (SICU). The Report indicated that a computerized tomography (CT) scan of Resident #1's head on 08/23/24 at 4:00 A.M., revealed worsening subdural and subarachnoid hemorrhages compared to a prior CT scan done on 08/22/24. The Report indicated that Resident #1's injuries were deemed non-operative given his/her Do Not Resuscitate/Do Not Intubate status. The Report indicated that Resident #1 also had an occipital (back of head) wound that required staples for closure, a right temporal bone (side of skull) fracture, and a right clavicle (collar bone) fracture. The Report indicated that Resident #1 was sent back to the facility on [DATE]. Resident #1 was admitted to the Facility in March 2017, diagnoses included dementia and major depressive disorder. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 06/05/24, indicated he/she was dependent on staff for care and had severe cognitive impairment. Review of Resident #1's Activities of Daily Living Care Plan, reviewed and renewed with his/her June 2024 Quarterly MDS, indicated that Resident #1 required a Hoyer lift with the assistance of two staff members for transfers. Review of Resident #1's Behavior Care Plan, reviewed and renewed with his/her June 2024 Quarterly MDS, indicated that if Resident #1 resists ADLs, reassure him/her, leave and return five to ten minutes later to try again. During an interview on 09/26/23 at 3:03 P.M., (which included a review of her Written Witness Statement, dated 08/23/24), CNA #1 said she knew Resident #1 transferred with a mechanical lift and that two staff members were required to do the transfer. CNA #1 said she was in Resident #1's room waiting for CNA #2 to come and assist her. CNA #1 said Resident #1 was seated in his/her wheelchair on a Hoyer lift pad, but it was not attached to the Hoyer lift yet. CNA #1 said Resident #1 started yelling, my butt hurts, so she (CNA #1) attached the Hoyer lift pad straps to the Hoyer lift, pressed the lift button on the Hoyer lift, and lifted him/her (Resident #1) up a little. CNA #1 said when she lifted Resident #1 up with the Hoyer lift, his/her combative behavior worsened and Resident #1 fell forward out of the Hoyer pad onto the floor. CNA #1 said she was standing in front of Resident #1 when she lifted him/her up, but was unable to stop him/her (Resident #1) from falling to the floor and hitting his/her head. CNA #1 said that she did not wait for CNA #2 to assist her [with the transfer] because Resident #1 was yelling, but said she should have waited. During a telephone interview on 10/02/24 at 10:31 A.M., (which included a review of a statement taken during a telephone interview conducted by the Director of Nurses, dated, 08/23/24), CNA #2 said she knew Resident #1 well and that two staff members were required to transfer him/her safely. CNA #2 said on 08/22/24, she was providing care to another resident, when she heard CNA #1 yell her name. CNA #2 said she ran to Resident #1's room, and when she entered Resident #1's room, she saw Resident #1 lying on the floor with blood around his/her head. During an interview on 09/26/24 at 11:21 P.M., (which included a review of her Written Witness Statement, dated 08/22/24), Nurse #1 said she was familiar with Resident #1 and that he/she required a Hoyer lift with two staff members present to assist with his/her transfers. Nurse #1 said CNA #1 and CNA #2 called her to Resident #1's room, and when she entered Resident #1's room, she saw Resident #1 lying on the floor on his/her back between the bed and the Hoyer lift, and he/she had blood coming from his/her head. Review of a Nurse Progress Note, written by Nursing Supervisor #1, dated 08/22/24 at 7:35 P.M., indicated that Resident #1 was being transferred via Hoyer Lift, became anxious and agitated, was flailing and kicking, and then slid out of the Hoyer pad onto the floor hitting his/her head on the floor. The Note indicated Resident #1 was visibly bleeding from a laceration on the back of his/her head. The Note indicated that Resident #1's mobility order was Hoyer lift with assistance of two staff members. During an interview on 09/2624 at 1:18 P.M., Nursing Supervisor #1 said CNA #1 told her that Resident #1 had been yelling, kicking, and flailing in his/her wheelchair, and screaming that his/her butt hurt. Nursing Supervisor #1 said CNA #1 told her that she (CNA #1) had tried to relieve pressure on Resident #1's buttocks by lifting him/her up [with the Hoyer lift], while she waited for CNA #2 to come to Resident #1's room to assist her. Review of an Employee Warning Form, dated 08/23/24, completed by the Staff Development Coordinator (SDC) indicated that CNA #1 was issued a written warning related to Resident #1's fall from the Hoyer lift. During a telephone interview on 10/03/24 at 12:08 P.M., the Staff Development Coordinator (SDC) said she completed the Employee Warning Form on 08/23/24 for CNA #1 because she (CNA #1) lifted Resident #1 up in the Hoyer lift without another staff member present to assist her, which caused Resident #1 to fall. The SDC said that per Facility Policy, two staff members are required to be present for all Hoyer lift transfers. The SDC said that a transfer begins as soon as a staff member uses a Hoyer lift to begin lifting the resident from the surface he or she is seated on. During an interview on 09/26/24 at 11:40 P.M., Unit Manager #1 said that Resident #1 is dependent on staff for all care, and said he/she can be combative during care. Unit Manager #1 said if Resident #1 becomes combative during care, then the CNAs should tell the nurse, and reapproach the resident later. The Unit Manager said two staff members are always required for Hoyer lift transfers. During an interview on 09/26/24 at 1:37 P.M., the Director of Nurses (DON) said that two staff members are required to provide assistance to any resident when using a Hoyer lift for a transfer. The DON said CNA #1 told her that the Hoyer pad was connected to the Hoyer lift and that she slightly lifted Resident #1 with the Hoyer without the assistance from another staff member. The DON said that CNA #1 also told her that when she (CNA #1) began attaching the Hoyer straps to the Hoyer lift, that Resident #1 became more agitated and combative. The DON said that after this incident, for any resident requiring a Hoyer lift for transfers, two staff members must enter the resident's room simultaneously. On 09/26/24, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction provided is as follows: A. 8/22/24, Nursing immediately assessed Resident #1 for injuries, 911 was initiated and he/she was transferred to the Hospital Emergency Department, he/she returned within 24 hours. B. 8/23/24, The Staff Development Coordinator (SDC) initiated staff education on the use of mechanical lifts and all nursing staff were required to complete an additional Mechanical Lift competency that included return demonstration. C. Effective 08/23/24, daily visual observation audits by Nursing administration on the day and evening shifts were initiated to ensure two staff members were present for Hoyer lift transfers. Observation Audits will continue for 60-90 days D. 8/24/24, Resident #1 returned to the facility and his/her Comprehensive Care Plan was reviewed and revised. E. 8/26/24, The Facility recognized that all residents have the potential to be affected by the same deficient practice, and the DON completed a facility-wide audit for all Residents requiring Hoyer lifts which included a review of their Comprehensive Care Plans. F. 09/03/24, the Director of Rehabilitation (DOR) completed facility-wide audit of all residents requiring a Hoyer lift, to ensure the correct Hoyer pads were being used on all residents according to manufacturer's guidelines. G. 09/10/24, the area of concern and data collected, was presented at the Facility's Quality Assurance Performance Improvement (QAPI) Committee Meeting, and a QI project was developed. H. The Administrator, the Director of Nursing and/or their designees will be responsible for overall compliance.

Based on interview, record and policy review, the facility failed to ensure that the Pneumococcal (any infection caused by bacteria called Streptococcus pneumoniae, or pneumococcus that can range from ear and sinus infections to pneumonia and bloodstream infections) Vaccination was offered to and/or administered as required to one Resident (#51) in five applicable residents, out of a total sample of 18 residents. Specifically, the facility failed to provide documentation evidence that Resident #51 was offered the Pneumococcal Vaccine (also referred to as Pneumovax) or did not receive the Pneumococcal Vaccine due to medical contraindication or refusal when: -The Resident was not up to date with his/her Pneumococcal vaccination status. -The Resident was eligible to receive a dose of Pneumococcal Vaccine upon his/her admission to the facility. Findings include: Review of the CDC guidelines titled Pneumococcal Vaccination Timeline for Adults, dated 3/15/23, indicated the following for adults aged [AGE] years and older: -Make sure your patients are up to date with Pneumococcal Vaccination. -If one dose only of PPSV23 (Pneumovax 23: Pneumococcal polysaccharide vaccine used to protect against 15 types of pneumococcal bacteria that commonly cause serious infections in adults) has been received at any age, . one dose of PCV20 (Prevnar 20: vaccine used to protect against 20 types of pneumococcal bacteria that commonly cause serious infections in adults) . should be administered no earlier than one year following the administration of the prior PPSV23 dose. Review of the facility policy, titled Policy for Pneumonia Vaccination, dated 2024 indicated: -It was the facility's policy that all residents over the age of [AGE] years be offered the Pneumonia vaccine. -Residents who were previously vaccinated with at least one dose of PPSV23 before or after age 65 should receive a single dose of PCV20. -The PCV20 should be administered at least one year after the PPSV23. Resident #51 was admitted to the facility in February 2023 with diagnoses including: Chronic Obstructive Pulmonary disease (COPD: a chronic lung disease that causes obstructed airflow and breathing problems) and Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment, and interferes with daily life activity). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #51 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of six out of 15 total points. Review of Resident #51's clinical record indicated that Resident #51: -was [AGE] years of age or older. -Healthcare Proxy (HCP: a person assigned to make healthcare decisions of behalf of the resident) was invoked on 2/27/23, due to a diagnosis of Dementia. -received one dose of Pneumococcal Polysaccharide Vaccine (PPV) on 1/1/98. -had not been administered the Pneumococcal Vaccine since he/she had been admitted to the facility in February 2023. Review of Resident #51's Immunization Record Information Form, dated 2/27/23, indicated the following: -Resident #51's HCP signed the Immunization Record Information Form. -The section to indicate whether the Resident had already received Pneumococcal vaccination, wanted the Pneumococcal vaccine, or did not want the Pneumococcal vaccine was blank. Review of Residents #51's April 2024 Physician orders included an order, initiated 2/27/23 with no stop date, which indicated: May have Pneumovax. Review of Resident #51's Massachusetts Immunization Information System (MIIS) record, undated, provided by the facility indicated the following: -The Resident received Pneumococcal PPV on 1/1/98. -The Resident was due to receive Pneumococcal PCV. Further review of Resident #51's MIIS record indicated no evidence that the Resident ever received any Pneumococcal Vaccine after 1/1/98. During an interview on 4/19/24 at 2:31 P.M., the Infection Preventionist (IP) said the facility obtained residents' vaccination statuses using the facility's Immunization Record Information Form when residents are admitted to the facility. The IP said she was responsible to review the Immunization Record Information Forms completed on residents' admissions to the facility and if any or all portions of the form were incomplete, she would follow-up with the resident or HCP (whichever was indicated as the responsible party) to determine whether vaccination had been completed or if the resident/HCP wanted or did not want vaccines to be administered. The IP said she was also responsible to track residents' vaccination statuses and if residents' vaccination statuses were not up to date, facility staff would offer them vaccines. The IP said all residents had an order from the Physician for Pneumococcal vaccination upon admission to the facility and that the facility adhered to CDC guidelines for Pneumococcal Vaccine administration. The IP also said she had been working on an audit of all residents in the facility relative to Pneumococcal vaccination status since she had started at the facility as the IP (which was in early 2021), as the facility was not in compliance with the requirements for Pneumococcal vaccinations for residents. The IP said at the time of the interview that the facility was still not in compliance for resident Pneumococcal vaccinations because the facility was focusing on administration of the most recent COVID-19 booster, per instruction of the Physician. The IP further said that Resident #51 had been eligible to receive a Pneumococcal Vaccine when he/she was admitted to the facility in February 2023 and that the IP would have to review the Resident's record to determine whether the vaccine had been administered. During a follow-up interview on 4/23/24 at 12:21 P.M., the IP said Resident #51 had been at the facility since February 2023, with a Physician's order for administering the Pneumococcal Vaccine. The IP also said Resident #51's Immunization Record Information Form had been signed by the Resident's HCP, but the section relative to Pneumococcal vaccination was blank, and the IP had not followed up with the Resident's HCP relative to Pneumococcal vaccination prior to the surveyor's inquiry. The IP said Resident #51's Pneumococcal Vaccine was not up to date. During an interview on 4/23/24 at 1:55 P.M., the facility Physician said if residents at the facility had already received a dose of PPSV23 and PCV13, the residents were considered to be up to date with their Pneumococcal Vaccine series and consideration of eligibility for providing one dose of PCV20 would be addressed after these residents received the most recent booster for COVID-19. The Physician also said the facility should have a protocol in place for Pneumococcal Vaccine administration to residents and if a resident was not up to date with their Pneumococcal Vaccine, the protocol should be followed. The Physician said he would have to be sure the facility had a protocol in place and that they followed the protocol. The surveyor informed the Physician that the facility provided a copy of their Policy for Pneumococcal Vaccination which indicated: -Residents who were previously vaccinated with at least one dose of PPSV23 before or after age 65 should receive a single dose of PCV20. -The PCV20 should be administered at least one year after the PPSV23. At this time, the Physician said if Resident #51's immunization record was accurate, the Resident would have required one dose of PCV20 to be considered up to date with the Pneumococcal Vaccine. The Physician further said the facility should have followed their policy.

Based on policy review, record review, and interview, the facility failed to ensure its staff provided the appropriate care and services related to a pressure ulcer for one Resident (#77) out of two applicable sampled residents. Specifically, the facility failed to ensure its staff regularly measured the wound and re-assessed the effectiveness of the wound treatment, resulting in a hospitalization for surgical debridement (removal of devitalized (dead) tissue). Findings include: Review of the facility's policy for Skin Assessment and Decubitus Prevention, dated April 2016, indicated the following: -Measure wounds weekly and document size, depth, description and drainage. Review of the facility's policy for Treatment Protocol for Pressure Ulcers, dated December 2014, indicated the following: Policy-For residents with a pressure ulcer, notify the Physician of any change in condition and consult with the Physician if the wound does not demonstrate an improved condition after 15 days of the same treatment. Resident #77 was admitted to the facility in July 2021. Review of the May 2022 Treatment Administration Record (TAR) indicated the following: -Apply small amount of Calazime (skin protectant) to abrasion to the left of the coccyx followed by a foam dressing for protection. Review of the June 2022 TAR indicated the following: -Apply small amount of Calazime to abrasion to the left of the coccyx followed by a foam dressing for protection. - The order was signed off as administered daily from 6/1/22 through 6/15/22 (except on 6/8/22 which was left blank). -The wound bed was described as pink from 6/1/22 through 6/12/22. -From 6/13/22 through 6/15/22 the wound bed was described as white. Review of a Progress Note, dated 6/15/22, indicated: - the Resident had an area to the left of his/her coccyx that had spread and had slough (dead tissue that needs to be removed for healing to take place). -A new order for Santyl (used to remove dead tissue) to the coccyx daily was obtained. Further review of the June 2022 TAR indicated the following: -Coccyx open area: Wash with normal saline, pat dry, apply Santyl then cover with foam adhesive dressing. - Monitor for signs and symptoms of infection every day shift. -From 6/16/22 through 6/20/22 the wound bed was described as pink. -On 6/21/22 the wound bed was described as white. -From 6/22/22 through 6/30/22 (except 6/29/22 which was left blank), the wound bed was described as red -There were no documented measurements of the wound. Review of the July 2022 TAR indicated the following: -Coccyx open area: Wash with normal saline, pat dry, apply Santyl then cover with foam adhesive dressing. -Monitor for signs and symptoms of infection every shift. -From 7/1/22 through 7/4/22 the wound bed was described as red -From 7/5/22 through 7/9/22 the wound bed was described as white -There were no documented measurements of the wound until 7/7/22, when the wound measured 4.9 centimeters (cm) x 1.2 cm x 0.1 cm. Review of a Progress Note, dated 7/9/22, indicated the Resident was sent to the emergency room (ER) for an evaluation at the request of his/her Health Care Proxy (HCP). Review of a Progress Note, dated 7/10/22, indicated the Resident was admitted to the hospital with diagnoses of fever, decubitus ulcer and weakness. Review of the hospital's History and Physical, dated 7/9/22, indicated the following: -The Resident had a Stage 3 decubitus ulcer on the sacral region with a possible lower back abscess. (Stage 3-defined by the National Pressure Ulcer Advisory Panel to be a full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar (a dry, dark scab or falling away of dead skin) may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur). Review of the hospital's Wound Specialist Note, dated 7/11/22, indicated the following: -Sacralcoccygeal area- unstageable pressure ulcer 3.0 cm x 4.0 cm full thickness skin and tissue loss in which extent of damage can not be confirmed due to wound obscured by eschar. -Wound bed is soft, tan brown moist devitalized tissue with area of deep tissue injury extending above superior edge of wound bed 1.0 cm x 2.0 cm. -Peri wound is macerated (due to skin being in contact with moisture for too long) -Recommendations: surgical debridement of devitalized tissue to initiate advanced wound care for treatment. Review of the hospital's Physical Exam, dated 7/13/22, indicated the following: -The Resident underwent a bedside debridement of a Stage 3 sacral pressure ulcer on 7/11/22. -There was no clear evidence of infection during the debridement, but a small amount of necrotic tissue remained at the base and possible at the skin edges. -Recommend debridement in the operating room on 7/14/22. During an interview on 10/14/22 at 12:59 P.M., with the Director of Nurses (DON) and Unit Manager (UM) #1, the DON said when a resident developed a wound the Unit Manager (UM) was responsible to determine what type of wound it was (pressure, arterial, vascular, trauma). UM #1 said the Resident was on her unit when he/she developed the coccyx wound. UM #1 said the wound was a pressure ulcer. She said it started as an abrasion and then it got worse (effective 6/15/22). When the surveyor asked her how it was worse, she said it was white, which indicated slough. She notified the Physician who gave the order to start Santyl. UM #1 said if there are no results from a wound treatment in 14 days they were supposed to re-evaluate the treatment. When the surveyor asked how it was determined if the treatment was effective, she said they based it on the color and size of the wound. When the surveyor asked UM #1 if she could show documentation of wound measurements, she said she would have to look into it. UM #1 reviewed the June 2022 and July 2022 TARs and said that the wound was documented as being white in July which indicated a deterioration. She said based on the July TAR the wound got worse and they did not change the treatment. When the surveyor asked how wound measurements were made available to the Physician or other members of the clinical team, the DON said only the nurses needed to have access to that information. The DON said at the time of this wound, there was no wound team. She said the Resident was discussed during daily nursing meetings. When the surveyor asked if there was any documentation to show Resident #77 had been discussed, both the DON and UM #1 said no. The DON said that even if the wound had deteriorated on 7/5/22, Santyl was the best debrider they could use in-house since they did not have a surgeon who could do a bedside debridement. When the surveyor asked if the facility had tried to send the Resident out for wound care, the DON shook her head and said absolutely not and said that the Resident was mentally unstable and would not have tolerated a transfer. When the surveyor asked if the Physician was contacted for a different treatment, the DON and UM #1 said they both thought Santyl was the best option. When the surveyor pointed to the most recent Physician note (dated 7/6/22) that did not reference the wound at all, the DON said the Physician knew all about it. During an interview on 10/14/22 at 2:41 P.M., UM #1 said they had not been able to find additional documents or wound measurements. During an interview on 10/17/22 at 2:38 P.M., the Physician said this Resident was under his care during the Resident's stay at the facility. The Physician said he relied on the nursing staff to tell him if anything major was going on. He said they told him at some point that the Resident had a wound and they were using Santyl. He said he was never told the status of the wound or if it had worsened. When the surveyor asked if he had ever seen the wound, the Physician said no. Refer to F580

Based on record review, and interview the facility failed to ensure its staff implemented procedures to ensure all staff were fully vaccinated for COVID-19, to stop the spread of infection. Specifically, staff failed to ensure that two contracted staff, out of a total of four sampled contracted staff, were fully vaccinated for COVID-19 as required, before allowing them to enter and work at the facility. Findings include: Review of the facility COVID-19 screening documentation for 10/17/22 indicated contracted staff #1 and #2 were in the facility to repair a refrigerator in the facility kitchen. During an interview on 10/17/22 at 12:41 P.M., the Infection Control Nurse said that the refrigerator repairmen indicated, on the facility COVID-19 screening questionnaire dated 10/17/22, that they were vaccinated for COVID-19. She said the repairmen started working in the facility the prior Thursday (on 10/13/22). She also said that she did not have any evidence of COVID-19 vaccination for either repairman and that when she called the refrigerator repair company after the surveyor's inquiry on 10/17/22 to obtain proof of vaccination, she was told that the repairmen were not vaccinated for COVID-19. She said that she usually obtained evidence of vaccination status for contracted staff before they came to the facility, and she should have obtained evidence that the refrigerator repairmen were fully vaccinated before they came into the facility to work, as required, but she did not.

Based on observation and interview, the facility failed to A. follow infection control practices in response to COVID-19 by not appropriately disposing gloves after interacting with residents on 2 of 2 units and B. not [MEDICATION NAME] social distancing on the dementia unit. Findings include: A. Review of the Centers for Disease Control (CDC) Guidelines for Hand Hygiene in Health-Care Settings, dated 10/25/02 (https://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf) indicated the following: Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient, and do not wash gloves between uses with different patients. On 6/25/20 at 9:00 A.M., the surveyor made observations on the 4th floor. At 9:05 A.M., the surveyor observed Certified Nursing Aide (CNA) #1 walking down the hallway holding soiled gloves in her hands and threw them away in trash bin near the water cooler. The surveyor observed the trash bin next to the water cooler and observed multiple pairs of soiled gloves in the bin. At 9:15 A.M., the surveyor observed CNA #2 enter a residents room and say she was going to assist the resident with using the rest room. At 9:25 A.M., CNA #2, exited the resident's room holding her soiled gloves, threw them in the trash bin next to the water cooler with her right hand, and closed the cover of the trash bin with her left hand. On 6/25/20 at 9:35 A.M. the surveyor made observations on the 2nd floor: At 9:40 A.M., the surveyor observed CNA #3 exit the shower room wearing gloves and carrying a bag of soiled linen. CNA #3 disposed of the bag of soiled linen in the cart and returned to the shower room without removing her soiled gloves. CNA #3 was then observed leaving the shower room a second time while wearing gloves, entered a resident room, obtained an adult brief, and re-entered the shower room without changing gloves or [MEDICATION NAME] hand hygiene. At 9:45 A.M., the surveyor observed CNA #3 wearing gloves in the small activity room pushing the hoyer lift out of the room and into a resident room, then returned in to the small activity room and began to move residents' wheelchairs without changing gloves or [MEDICATION NAME] hand hygiene. At 9:45 A.M., the surveyor observed CNA #4 walking down the hallway holding soiled gloves in her hand. CNA #4 entered the clean utility room, began to run the faucet, threw the soiled gloves in the trash, and began to wash her hands. During an interview with the Infection Control Coordinator on 6/25/20 at 10:15 A.M., she said that staff are educated and are expected to remove their gloves and to perform hand hygiene before leaving resident rooms, and not to carry soiled gloves down the hallways. B: Review of the Centers for Disease Control (CDC) recommendations of social distancing in response to COVID-19 indicated the following: [MEDICATION NAME] social distancing also called physical distancing, means keeping space between yourself and other people . To practice social or physical distancing stay at least 6 feet (about 2 arms' length) from other people. COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a prolonged period. Spread happens when an infected person coughs, sneezes, or talks, and droplets from their mouth or nose are launched into the air and land in the mouths or noses of people nearby. The droplets can also be inhaled into the lungs. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/social-distancing.html During observations on the dementia unit on 6/25/20 at 9:55 A.M., the surveyor observed approximately 4 residents in reclining wheelchairs asleep in the small activity room. None of the residents were wearing masks and were seated approximately 3 feet apart. Nurse #1 told the surveyor that all the residents would not tolerate wearing masks due to their dementia. Nurse Supervisor #1 arrived and agreed that the residents were not 6 ft apart and began spacing their wheelchairs apart. At 10:00 A.M., the surveyor observed approximately 17 residents (not wearing masks) in the large activity room in the dementia unit. Some residents were seated in arm chairs that were touching and others were seated in wheelchairs that were within arms length of one another. Program Coordinator #1 was present and said that due to the residents' dementia [DIAGNOSES REDACTED]. At the time of the observation, no residents were agitated or wandering. The majority of residents were dozing and all were quiet and peaceful. The Program Coordinator acknowledged that the arms of the arm chairs were touching and that there was no physical distance made between the furniture that would provide any form of distancing between residents and that a love seat (a seat intended for two people to sit together on) was present in the room. The Program Coordinator said she would call maintenance to come and rearrange the furniture.

Based on observation, record review and interview, the facility staff failed to investigate an injury of unknown origin (a fifth metacarpal fracture - the long bone that connects the finger to the wrist) for 1 Resident (#65) from a total sample of 21 residents. Findings include: Resident #65 was admitted to the facility in 9/2018 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set assessment dated [DATE] indicated Resident #65 required limited assistance for bed mobility, transfers in and out of bed, toilet use and personal hygiene. He/she walked with a walker, required extensive assistance for dressing and ate independently. Review of Resident #65's nursing progress note dated 7/1/19 at 4:30 P.M., indicated Resident #65 complained of right wrist pain and the area was slightly swollen and warm to touch. It further indicated that Resident #65 had presented with confusion and hallucinations earlier in the day. Review of Resident #65's nursing progress note dated 7/2/19 at 11:01 [NAME]M. indicated treatment for [REDACTED].#65 continued to yell out with care. Review of Resident #65's nursing progress note dated 7/3/19 at 11:19 [NAME]M. indicated a physician's orders [REDACTED]. The x-ray results indicated an acute mildly displaced oblique fracture at the 5th metacarpal. The physician ordered a wrist brace to the right hand, ice to the area for 20 minutes every 4 hours as needed and an orthopedic consult. During an interview on 9/18/19 at 11:04 [NAME]M., the Director of Nursing said that when an incident occurs, the process she follows is that she would begin an investigation by looking at the resident, reviewing the progress notes, speaking with family, the unit manager and reviewing the incident report. She further said she would get statements from staff if she felt something was going on. Review of the [NAME]any Health Center incident investigation policy and procedure document dated 12/2016 indicated it is the policy of the facility to investigate any incident or injury that may occur. Once the resident has been attended to, the nurse should begin a root cause analysis investigation and complete the resident accident report. During an interview on 9/19/19 at 8:32 [NAME]M., the Director of Nursing said she did not get statements from staff for this injury because after reading progress notes related to Resident #65, she was under the impression that the resident's family member thought the injury could have happened when the family member took the resident to the bathroom. The Director of Nursing said she was satisfied with that explanation and did not investigate further. During an interview on 9/19/19 at 10:35 [NAME]M., Unit Manager #1 said Resident #65 had a history of [REDACTED]. He/she was known to hit and lash out at family and staff. Unit Manager #1 said, when an incident such as this happens, a brown incident report form would be completed at the time of the incident. A brown incident report form was not completed when the right 5th metacarpal fracture was diagnosed . Review of an example of the facility's Resident Accident/Incident Report form (brown form) provided by the facility indicated, in addition to the resident information required, the report requires the results of the investigation be documented on the 2nd page of the form as well as an area for Administrative follow up. There was no evidence provided by the facility to indicate that the facility had completed a thorough investigation into the cause of Resident #65's 5th metacarpal fracture to rule out abuse, neglect, or mistreatment as the cause of Resident #65's fracture.

Based on interview and record review the facility staff failed to follow the care plan related to falls for one Resident (#64) out of 20 sampled residents. Findings include: Resident #64 was admitted to the facility in 8/2016 with [DIAGNOSES REDACTED]. Review of the care plan for falls, initiated 8/8/16 with goal date of 1/13/19, indicated the resident was at risk for falls due to confusion, disorientation, cognitive loss, poor sense of direction, poor safety awareness, decreased balance, incontinence, easy distractibility, decreased ability to sequence tasks, and decreased attention span secondary to advanced dementia. The goal was resident would be free from injury. Further review indicated an intervention, dated 4/3/18, for the resident to ambulate with rolling walker and supervision, (this intervention was discontinued on 10/29/18). Review of a Progress note, dated 10/28/18 at 12:14 A.M., indicated the resident sustained [REDACTED].M., and was observed lying on the floor face down in another resident's room. The resident sustained [REDACTED]. The resident was sent to the local emergency room (ER) for evaluation. Review of a Progress note, dated 10/28/18, indicated the resident returned from the ER at 5:30 P.M. Review of the Fall Investigation Report, dated 10/28/18, indicated the resident sustained [REDACTED].M. on the floor in another resident's room. Further review indicated the resident ambulated from the dining room to the activity room with supervision from a Certified Nurses Aide (CNA). The CNA reportedly told the Activity Staff member to help this resident. Under the section of the form titled Action Plan the following was indicated: Requires to be supervised at all times during ambulation and to be secure that he/she is in the Activity Room and seated in a chair. Activity Staff need to be aware at all times for safety. Review of the Nurse Practitioner's note, dated 10/29/18, indicated the resident had sustained an unwitnessed fall on 10/27/18 and as a result, sustained a laceration of the right parietal to mid occipital scalp (side to back of the head) that required 39 staples to close, laceration to mid forehead that required 10 sutures to close, laceration to upper lip that required 4 sutures to close, and a likely sprained right wrist. During an interview on 12/06/18 at 2:15 P.M. with the Director of Nurses (DON), she said that the resident walked from the Solarium to the activity room with 2 CNAs and there was commotion in the Solarium that the CNAs tended to and they never put this resident in a chair. The resident was later found in another resident's room on the floor with a head injury. The DON said there were several Activity Staff members on duty at the time but it was busy. During an interview on 12/06/18 at 2:26 P.M. with the DON she said she put herself in the staff's shoes and since it was so busy on the Dementia Special Care Unit (where this resident lived) she could understand how the resident got away. She said the resident was supposed to be supervised for all ambulation but that didn't happen. Please refer to F 689

Based on interview and record review the facility staff failed to provide adequate supervision to prevent a fall with major injury for one resident (#64) out of 20 sampled residents. Findings include: Resident #64 was admitted to the facility in 8/2016 with [DIAGNOSES REDACTED]. Review of the care plan for falls, initiated 8/8/16 with goal date of 1/13/19, indicated the resident was at risk for falls due to confusion, disorientation, cognitive loss, poor sense of direction, poor safety awareness, decreased balance, incontinence, easy distractibility, decreased ability to sequence tasks, and decreased attention span secondary to advanced dementia. The goal was resident would be free from injury. Further review indicated an intervention, dated 4/3/18, for the resident to ambulate with rolling walker and supervision. Review of the Fall Risk Assessment, dated 7/16/18, indicated the resident was at high risk for falls as evidenced by a score of 18, (anything over 10 is considered high risk). Review of the Fall Risk Assessment, dated 10/13/18, indicated the resident continued to be at high risk for falls as evidenced by a score of 18. Review of the Quarterly Minimum Data Set Assessment, dated 10/16/18, indicated the resident had impaired long and short memory, severely impaired decision making ability, required extensive assist of one for transfers, and ambulated in the corridor with set up and staff supervision. Review of a Progress note, dated 10/28/18 at 12:14 A.M., indicated the resident sustained [REDACTED].M., and was observed lying on the floor face down in another resident's room. The resident sustained [REDACTED]. The resident was sent to the local emergency room (ER) for evaluation. Review of a Progress note, dated 10/28/18, indicated the resident returned from the ER at 5:30 P.M. Review of the Fall Investigation Report, dated 10/28/18, indicated the resident sustained [REDACTED].M. on the floor in another resident's room. Further review indicated the resident ambulated from the dining room to the activity room with supervision from a Certified Nurses Aide (CNA). The CNA reportedly told the Activity Staff member to help this resident. Under the section of the form titled Action Plan the following was indicated: Requires to be supervised at all times during ambulation and to be secure that he/she is in the Activity Room and seated in a chair. Activity Staff need to be aware at all times for safety. Review of the Nurse Practitioner's note, dated 10/29/18, indicated the resident had sustained an unwitnessed fall on 10/27/18 and as a result, sustained a laceration of the right parietal to mid occipital scalp (side to back of the head) that required 39 staples to close, laceration to mid forehead that required 10 sutures to close, laceration to upper lip that required 4 sutures to close, and a likely sprained right wrist. During an interview on 12/06/18 at 2:15 P.M. with the Director of Nurses (DON), she said that the resident walked from the Solarium to the activity room with 2 CNAs and there was commotion in the Solarium that the CNAs tended to and they never put this resident in a chair. The resident was later found in another resident's room on the floor with a head injury. The DON said there were several Activity Staff members on duty at the time but it was busy. During an interview on 12/06/18 at 2:26 P.M. with the DON, she said she put herself in the staff's shoes and since it was so busy on the Dementia Special Care Unit she could understand how the resident got away. She said the resident was supposed to be supervised for all ambulation but that didn't happen.

Based on observation, document review and interview, the facility staff failed to ensure that safe and adequate sanitation practices were maintained to minimize the risk of food borne illnesses. Findings include: During an initial tour of the main kitchen on 12/5/18 at 8:06 A.M., the following were observed; -The Food Service Director (FSD) and 2 other kitchen staff members had facial hair that was uncovered. -Oven racks were stored directly on the floor. -Sugar and Flour bins were labeled, however they both were undated. During this same time, the FSD said to the Surveyor that the oven racks should not have been stored directly on the kitchen floor. During a second tour of the main kitchen on 12/7/18 at 10:40 A.M., the following were observed; -The fan in the dishroom was observed to be dirty and dusty. It was on and blowing on the side of the dishroom where the clean dishes were coming out of the dishmachine. -Diet Aide #1 and the FSD had facial hair that was uncovered. -Review of the facility's Hazard Analysis and Critical Control Points (HACCP) Daily Taste Panel Chart to monitor food temperatures for 12/6/18 (breakfast, lunch and supper) and 12/7/18 (breakfast) indicated cold beverage and cold food temperatures had not been monitored and/or recorded. ` During an interview on 12/07/18 at 1:09 P.M., the FSD said the cold food and beverages temperatures had not been monitored and recorded, but should have been. He said everything that was served at a meal should be checked for appropriate temperatures, including cold items. He said the kitchen staff with facial hair will now be required to have it covered with a restraint. He also said the fan in the dishroom was dirty and he would have it cleaned.

Based on record review and interview, the facility staff failed to ensure 3 resident records (#4, #41 and #78) in a total sample of 20 residents, were complete and accurate. Findings include: The 3 resident records failed to ensure the orders on the Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) were accurately reflected in the signed Physician orders. Review of the facility's MOLST/Advanced Directive Policy, revised date 3/23/17, indicated the following; When indicated, physician's orders [REDACTED]. 1. Resident #4 was admitted to the facility in 8/2018. Review of the MOLST form, dated 1/3/18, indicated DNR, DNI, Do Not Use Non-invasive Ventilation, Do Not hospitalized (DNH), No Artificial Nutrition or Hydration and No [MEDICAL TREATMENT]. Review of the signed 10/2018 physician's orders [REDACTED]. 2. Resident #41 was admitted to the facility in 9/2018. Review of the MOLST, dated 10/2/17, indicated Attempt Resuscitation, Intubate and Ventilate, Use Non-invasive Ventilation, Transfer to Hospital, Undecided on [MEDICAL TREATMENT] and Use Artificial Nutrition and Hydration, but short term only. Review of the signed 10/2018 physician's orders [REDACTED]. During an interview on 12/06/18 at 2:24 P.M., when reviewing the MOLST and physician's orders [REDACTED].#41, Unit Manager #1 said the physician's orders [REDACTED]. 3. Resident #78 was admitted to the facility in 3/2017 with [DIAGNOSES REDACTED]. Review of the MOLST, signed 3/3/2017, indicated the resident requested to be DNR/DNI/DNH, no [MEDICAL TREATMENT], no artificial nutrition, use artificial hydration for short term only. Review of the signed physician's orders [REDACTED]. The order did not include the remainder of the resident's requests. During an interview on 12/6/18 at 10:34 A.M., Nurse #1 said the facility's policy was for the physician's orders [REDACTED].

Based on observation, interview and record review, the facility staff failed to obtain a Physician's order for the use of [REDACTED]. Findings include: Resident #42 was admitted to the facility in 11/2009 with [DIAGNOSES REDACTED]. Review of the facility's Policy and Procedure for Restraint Use, dated 11/2016, indicated the following: Procedure: An order must be obtained to initiate a restraint from the Physician or Nurse Practitioner. The order must be specific and specify the times the restraint should be use, length of use, and frequency of releases. Review of the Quarterly Minimum Data Set Assessment, dated 9/25/18, indicated the resident had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 2 out of 15 and used a restraint daily. Review of the signed Physician's orders, dated 11/30/18, indicated no order for use of the merry walker (a walker/chair combination). On 12/05/18 at 4:12 P.M., the Resident was observed to be dressed and ambulating in the merry walker in the hallway. During an interview on 12/06/18 at 10:47 A.M., Nurse #1 said the Resident used the merry walker. She reviewed the clinical record and was unable to find the Physician's order for it.

Based on observation and interview, the facility staff failed to ensure food was served at a safe and appetizing temperature on the Dementia Special Care Unit (DSCU). Findings include: Review of the facility's policy for Trayline Procedures, with a revision date of 3/2010, indicated the following: Policy: Food is maintained at proper temperatures during service. Purpose: To serve foods that meet resident expectations for palatable meals. Procedure: .Prior to the start of each meal period, there is an evaluation of the taste and temperature of food. This information is documented on a Taste and Temperature Log. Cold foods such as juices . are refrigerated during service or properly iced. Review of the facility's Hazardous Analysis Critical Control Points (HACCP) Daily Taste Panel Chart, indicated the following: Recommended Serving Temperatures (to ensure hot or cold food at point of consumption): Cold food: below 40 degrees Fahrenheit (F) Other entrees: 160 degrees Fahrenheit During an observation on 12/05/18 at 8:25 A.M., of the dining room on the DSCU that serves residents who are completely dependent or require extensive assistance for eating, the following was observed: The breakfast truck was delivered to the DSCU. Staff began to serve trays from the truck to the residents in the dining room. At 8:43 A.M., three residents in the dining room had not yet received their trays. At 9:02 A.M. two residents were still waiting for their trays, still waiting to be fed. At 9:05 A.M., there was still one resident waiting to be fed. At 9:14 A.M. the last tray was delivered to the resident who was waiting to eat. The Certified Nurses Aide (CNA) did not heat up any of the items on the tray. During an observation on 12/06/18 at 8:22 A.M., the breakfast truck was delivered to the DSCU. At 8:29 A.M. the first tray was passed. At 8:41 A.M. there were 7 residents in the dining room, all but one resident had a tray. At 9:07 A.M., there were 2 trays left in the truck. The surveyor then asked Nurse #1 if those residents were in the dining room and she said the CNAs were in the process of getting them out of bed. The Surveyor requested a thermometer to take the temperature of the food on one of the remaining trays. On 12/06/18 at 9:09 A.M., with the Registered Dietician (RD) the following temperatures were observed for the above stated tray: cream of wheat: 130 degrees F- warm to taste french toast puree: 123 degrees F- lukewarm to taste milk: 52 degrees F- did not taste cold Orange juice: 57 degrees F- did not taste cold yogurt: 60 degrees F- tasted to be near room temperature (Nurse #1 ordered 2 new trays for the residents who had not yet gotten out of bed). During an interview on 12/06/18 at 9:16 A.M., the RD said they had a lot of dependent residents and that's why it took so long to pass the trays. She said she would expect the hot food to be above 130 degrees F and the cold food to be under 60 degrees F, (the policy stated otherwise). Please refer to F 812

Based on interview and record reviews, the facility failed to ensure the ombudsman was notified of transfers out of the facility for 2 sampled Residents (#31 and #66) out of 20 sampled residents. Findings include: 1. Resident #31 was admitted to the facility in 5/2006. Review of the clinical record, indicated Resident #31 was transferred to the hospital for an evaluation on 10/14/18. Review of the clinical record did not indicate the ombudsman was notified in writing of the Resident's transfer out of the facility. 2. Resident #66 was admitted to the facility in 5/2015. Review of the clinical record, indicate Resident #66 was transferred to the hospital for evaluation on 11/9/18. Review of the clinical record did not indicate the ombudsman was notified in writing of the Resident's transfer out of the facility. During an interview on 12/06/18 at 1:15 P.M., the Director of Social Services said she does not notify the ombudsman when a resident is transferred to the hospital.

Based on record review and interview the facility staff failed to ensure that each resident received adequate supervision and effective interventions to prevent accidents for 2 of 9 applicable sampled residents (#4, and #10) out of a total sample of 19 residents. Findings include: Review of the facility Policy and Procedure for Post Fall Assessment and Investigation dated 5/2016 indicated to document the post fall interventions in the nurses notes. 1. For Resident #4, facility staff failed to utilize proper staffing while providing evening care resulting in an injurious resident fall. Resident #4 was admitted to the facility in 9/2010 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 2/16/16, indicated the resident was severely impaired cognitively with a Brief Interview for Mental Status (BIMS) score of 5/15 points, was totally dependent requiring 2 person assistance for positioning when in bed and toilet use, and required a mechanical lift with 2 assist for all transfers. Review of the updated 5/2016 Resident's Care Plan indicated the Resident was totally dependent for toilet use and required 2 person assistance for transfers and bed mobility. Review of the Resident Accident Report, dated 5/15/16 at 9:00 P.M., indicated the resident was receiving evening care, including position changes in bed to provide care, by 1 Certified Nursing Assistant (CNA), rather than 2 CNAs as planned. A CNA statement, dated 5/15/16, indicated the Resident's legs were going out of the bed, and the CNA tried to catch him/her from falling. Resident #4 fell out of bed and sustained a laceration to his/her head requiring 4 staples to the occipital area (back of head). During an interview on 8/2/16 at 10:15 A.M., Nurse #1 said the CNA did not follow the care plan and was terminated. 2. For Resident #10, the facility staff failed to develop effective fall interventions to prevent 2 unwitnessed resident falls in the bedroom. Resident #10 was admitted to the facility in 2/2011 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 7/7/15, indicated the resident was severely cognitively impaired with a BIMS score of 4 of 15 points and required limited assistance with mobility. Review of 7/2015 care plan for the resident to be free of injury daily, indicated the following interventions: -Ambulate with walker and one assist-remind to keep close to walker, -Provide frequent reminders regarding the use of walker for ambulation, -Extensive assist with Activities of Daily Living, -Extensive assist of 1 with all transfers, -Assist with eyeglasses, -Check for incontinence, -Keep involved with daily activities, -Give Vitamin D3 as ordered, -and Give calcium as ordered. Review of the Resident Accident Report, dated 7/26/15 at 1:15 A.M., indicated the resident was observed lying on the floor beside his/her bed and had been incontinent. The Administrative Follow Up section of the Accident Report indicated the resident had cognitive loss due to dementia and ambulated with walker and gait belt, and needed 2 assists with wheelchair to follow. It also indicated that the resident didn't remember he/she required assistance to the lavatory and the resident was not a candidate for a floor mat due to safety. Review of the Nurse's Notes for 7/26/15 indicated no post fall interventions to prevent further resident falls. Review of Resident Accident Report, dated 11/22/15 at 4:50 A.M., indicated the resident was observed lying on the floor next to his/her bed and had been incontinent. The Administrative Follow Up section indicated he/she was assisted with toileting on rounds at night. Review of the Nurse's Notes for 11/22/15 indicated no post fall interventions to prevent further resident falls. During an interview on 8/2/16 at 10:55 A.M., Assistant Director of Nursing (ADON) said the falls of 7/26/15 and 11/22/15 did not have any interventions to prevent unwitnessed nighttime falls in the resident's bedroom.

Based on record review and interview, the facility staff failed to follow the individualized care plan for 1 of 19 sampled residents (#4). Findings include: Resident #4 was admitted to the facility in 9/2010 with [DIAGNOSES REDACTED]. Review of the 5/24/16 Resident Care Plan indicated the Resident was totally dependent for toilet use and required two person assist with bed mobility (Resident unable to change position independently while in bed). Review of the Resident Accident Report dated 5/15/16 at 9:00 P.M., indicated the Resident was receiving evening care by 1 Certified Nursing Assistant (CNA). A CNA statement, dated 5/15/16, indicated the Resident's legs were going out of the bed and the CNA tried to catch him/her from falling. The Resident fell out of the bed and sustained a laceration to his/her head requiring 4 staples to the occipital area (back of head). During an interview 8/2/16 at 10:15 A.M., Nurse #1 said that the CNA did not follow the care plan for two person assistance during care, and was terminated.

Based on record review and staff interview, the Quality Assessment and Performance Improvement (QAPI) Committee failed to ensure the Medical Director and Director of Nursing attended the meetings as required. Findings include: Record review of the 2015-16 Quarterly QAPI Committee meeting attendance sheets indicated the following: -the facility's Director of Nursing was not present at the 8/14/15, 11/13/15, and the 2/12/16 meetings, as required, -the facility's Medical Director was not present at the 8/13/16 meeting, as required. During interview with the Administrator and the Education/QAPI Nurse on 8/2/16 at 3:00 P.M., both said that the Director of Nursing and Medical Director were expected to attend the quarterly QAPI meetings and did not do so due to vacations.

Based on record review and staff interviews the facility failed to ensure resident rights to formulate Advance Directives were followed for 2 sampled Residents #8 and #13) in a total of 19 sampled Residents and 2 Non-sampled Residents, (NS #A, NS #B). 1. For Resident #8, the facility failed to ensure a medical assessment to determine that Resident #8 lacked the capacity to make health care decisions was documented prior to activating the authority of the Health Care Proxy, according to the facility policy. Resident #8 was admitted to the facility from the hospital during 2/14 with [DIAGNOSES REDACTED]. Resident #8's BIMs score was 10 (0 low to 15 high). On 3/19/14 review of the medical record identified that on 2/14/14 physician orders [REDACTED]." An Advance Directive for a DNR and DNI on Resident #8 was signed by the HCP on 2/13/14. Further review of the record did not locate any documentation that the physician determined that Resident #8 was no longer capable of making health care decisions prior to activating the HCP nor any documentation by the Social Worker notifying the HCP, according to facility policy. On 3/20/14, interview with ADON #1 indicated that there was no documentation by the physician in the medical record regarding a determination of the Resident's health care decision capacity prior to activating the HCP. 2. For Resident #13, the facility failed to ensure a medical assessment to determine the Resident's lack of capacity to make health care decisions was documented prior to activating the authority of the Health Care Proxy (HCP), according to the facility policy. Resident #13 was admitted to the facility during 2/2014 with [DIAGNOSES REDACTED]. Resident #13's MDS dated , 2/12/14,documented on the BIMS a score of 08 (0 low to 15 high). On 3/24/14 review of the medical record revealed that the resident had a health care proxy dated 5/5/11. The record identified that on 2/5/14, physician orders [REDACTED]." An Advance Directive for a DNR and DNI on Resident #13 was signed by the HCP on 2/5/14. The physician's note dated, 2/7/14, does not address activating the health care proxy. Review of the hospital Transition Record (discharge summary) dated 2/5/14, stated that during the hospitalization the resident indicated he/she had an Advanced Directive. There was no documentation that the resident's health care proxy had been activated while the resident was in the hospital. During interview on 3/24/14 at 11:05 A.M., the Assistant Director of Nurses #2 (ADON#2) stated that the facility assumed that the HCP had been activated during two psychiatric hospitalization s prior to admission to the facility. Further review revealed there was no documentation that the physician determined that Resident #13 was no longer capable of making health care decisions prior to activating the HCP nor any documentation by the Social Worker notifying the HCP, according to facility policy. On 3/24/14 at 11:20, the Social Worker stated that she called the family that morning and informed them of the activation of the HCP. The ADON #2 said she/he would asked the physician to sign the activation on 3/25/14.